BACKGOUND AND OBJECTIVE: Natural Orifice Specimen Extraction (NOSE) has been postulated as an alternative approach to deliver the resected specimen out of peritoneal cavity through an anatomic passage rather than any abdominal incision after laparoscopic colorectal resections. This prospective study focused on the patients who underwent various laparoscopic left-side colorectal surgeries with intracorporeal anastomosis and transanal specimen extraction at our institute in the past 10 years with the specific aim to investigate if transanal approach can be accepted as a safe and effective method for extracting the specimen from abdominal cavity in laparoscopic colorectal surgeries.

METHODS: A prospectively designed database of a consecutive series of patients undergoing various laparoscopic colorectal surgeries with transanal specimen extraction for different left-side colonic as well rectal pathologies between April 1995 and May 2006 was analyzed on categories of age, gender, co-morbidities, preoperative diagnosis, indications for surgery, American Society of Anesthesiology Class, types of surgery, operating time, intraoperative blood loss, intra- and postoperative complications, tumor size, lymph node status, results of postoperative pathology, AJCC TMN Stage, length of hospitalization, cancer recurrence, and causes of death. Patient selection for laparoscopic colorectal surgeries with intracorporeal anastomosis and transanal specimen extraction was made on the basis of entities of diseases, size of the tumor, and distance of colorectal lesions to the anal verge.

RESULTS: 238 various colorectal procedures including 6 left hemicolectomy (2.5%), 83 sigmoidectomy (34.9%), and 149 low anterior resection (62.6%) were completed laparoscopically with intracorporeal anastomosis (ICA) and transanal specimen extraction (TASE). The straight and circular surgical stapling devices including Endo-GIA and EEA were used to create anastomosis intracorporeally in all 238 laparoscopic colorectal resections. Pathological evaluation of all the surgical specimens demonstrated 167 malignant tumors with various AJCC TMN stages (70.2%) and 69 diverticulitis (29%). The operating time for laparoscopic colorectal resections with ICA and TASE was 157.3 +/- 51.4 minutes, blood loss during the surgeries was 96.8 +/- 76.5 ml, and distance from the lower edge of the lesion to the anal verge was measured to be 11.8+/- 8.2 cm. One patient developing postoperative anastomotic leakage with leak rate of 0.42%, and overall rate of major complications after the surgeries is 2.1%. The length of hospital stay was 6.9 +/- 2.8 days. 2-year follow-up showed the development of anal stenosis in 3 patients (2.0%) and erectile dysfunction in one patient (0.67%) after the procedures. Lastly 7 out of 149 patients underwent laparoscopic low anterior resection with ICA and TASE were confirmed to have cancer recurrences with the 2-year local cancer recurrence rate of 4.7%, furthermore the patients having preopeative chemoradiation therapy had higher recurrence rate (11.3%) than that of the patients without (1.0%).

CONCLUSIONS: As a bridge to NOTES, transanal specimen extraction in laparoscopic colorectal surgeries is a safe and effective approach with low local cancer recurrence and other long as well as short-term postoperative complication rates, suggesting it can be integrated into laparoscopic colorectal surgeries for left-side colorectal pathologies including cancer. More importantly, NOSE does not unnecessarily traumatize other normal organs.

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